The Family Physician’s Role in Managing the Bariatric Surgery Patient

1
The Family Physicians Role in Managing the
Bariatric Surgery Patient

• B. Wayne Blount, M.D., MPH

2
Objectives

• Discuss non-surgical and surgical weight
  management options
• Identify appropriate surgical candidates and
  counsel patients about the importance of
  compliance with the post-operative regimen
• Review the current surgical treatment options and
  their effectiveness including possible side
  effects and complications
• Discuss follow-up care and long-term management
  of the post-bariatric surgical patient

3
The Obesity Epidemic

• 67 are overweight or obese
• 117 billion spent in 2000 to treat the medical
  consequences of overweight and obesity
• 112,000 deaths/year attributed to obesity

Mokdad, A. H., Marks, J. S., Stroup, D. F.,
Gerberding, J. L. (2004). Actual cause of death
in the United States. Journal of the American
Medical Association, 291 (10), 1238-1245.
4
The Obesity Epidemic

• CLINICIANS SHOULD SCREEN ALL ADULT PATIENTS FOR
  OBESITY AND OFFER INTENSIVE COUNSELLING
  BEHAVIORAL INTERVENTIONS TO PROMOTE SUSTAINED
  WEIGHT LOSS FOR OBESE PATIENTS
• B Recommendation
• USPSTF

5
The Obesity Epidemic

• Use
• BMI tables
• Waist Circumference
• Measured _at_ narrowest part of waist between lower
  rib cage unbilicus

6
Health Burden

• Type 2 diabetes
• Hypertension
• Cardiovascular disease
• Stroke
• Dyslipidemias
• Osteoarthritis
• Cancers
• Sleep apnea
• Gall bladder disease
• Female infertility
• Psychological issues

7
The Current Interventions

• Popular diets reduce caloric intake by
  restricting certain foods and limiting portions,
  i.e. by counting calories, fat or carbs
• Medically supervised diets
• Very Low Calorie Diets (VLCD)
• Liquid Fasts
• Referral to a nutritionist or dietician
• Exercise regimens
• Medications (sibutramine, orlistat)
• Cognitive Behavioral Training
• Bariatric Surgery

8
The Current Interventions
9
Effect of 4 Diets on Wgt Loss

• Atkins, Ornish, Wgt Watchers, Zone
• 1 year
• 25 with adequate adherence
• 4.6 to 7.3 loss _at_ 1 yr in those 25
• Which diet didnt matter
• Exercise did matter

10
Why Diets Often Fail

• Require lot of time and energy
• Cause feelings of deprivation
• Dont address why people overeat
• Disrupt metabolism

11
Bariatric Surgery

• Number of procedures performed has increased
  10-fold
• 14,000 in 1993
• 140,000 in 2004
• gt 200,000 in 2005
• gt 300,000 in 2007

12
Bariatric Surgery

• Evidenced Based Recommendation
• Bariatric surgery leads to sustainable long-term
  weight loss and may reduce obesity-related
  comorbities such as diabetes mellitus and
  obstructive sleep apnea. It is not clear which
  surgical procedure is the safest and most
  effective.
• Recommendation B
• From The Cochrane Database of Systematic Reviews
  available at ttp//www.cochrane.org/reviews/en/ab0
  03641.html

5
13
The Family Physicians Role

• Assist their patients in their weight management
  efforts
• Identify potential surgical candidates
• Counsel patients about their options and the
  risks and outcomes of each
• Understand the post-surgical dietary regimen
• Monitor patients for short and long-term
  complications of bariatric surgery

14
Indications

• Body Mass Index of 40 kg per m2
• Body Mass Index of 35 kg per m2 with significant
  comorbities
• Type 2 diabetes
• Obstructive sleep apnea
• Coronary artery disease
• Debilitating arthritis
• Online BMI calculator available _at_
  http//familydoctor.org

Gastrointestinal surgery for severe obesity.
Consensus Statement 199191-20. Available
online at http//consensus .nih.gov/1991/1991GISur
geryobesity084html.htm.
15
Indications (continued)

• Previous failed weight loss attempts using an
  integrated weight loss program including
• Dietary modification
• Behavioral support
• Appropriate exercise
• Appropriate motivation and psychological
  stability to understand risks and benefits of the
  procedure
• The commitment to lifelong postoperative
  lifestyle changes and medical surveillance

Gastrointestinal surgery for severe obesity.
Consensus Statement 199191-20. Available
online at http//consensus .nih.gov/1991/1991GISur
geryobesity084html.htm.
16
Contraindications

• Poor surgical candidates inadequate
  cardiopulmonary reserve, drug or alcohol
  dependency, impaired intellectual capacity
• Unable or unwilling to comply with post-op
  lifestyle changes, diet, supplementation, f/u
• Unstable psychiatric illness or eating disorders
• Uncontrolled coagulation problems or cannot be
  removed from coagulation therapy
• For Lap Band Intra-abdominal adhesions or
  potential for inadequate pneumoperitoneum

17
Pre-Op Evaluation

• Patients should be evaluated by a team medical
  surgical, psychiatric and nutritional experts to
  determine whether they are candidates for
  bariatric surgery
• Pre-op physical and evaluation

Gastrointestinal surgery for severe obesity.
Consensus Statement 199191-20. Available
online at http//consensus .nih.gov/1991/1991GISur
geryobesity084html.htm.
18
Pre-Op Evaluation (continued)

• Studies may include
• EKG
• CXR
• Echocardiogram
• Cardiac cath
• Polysomnography/sleep study
• Gallbladder ultrasound
• UGI or EGD
• Possible cardiac, pulmonary and psychiatry
  consultations

19
Pre-Op Evaluation (continued)

• Labs may include
• Fasting comprehensive metabolic panel
• LFTs including albumin
• Lipid panel
• CBC
• UA
• Hgb A1C
• Oral glucose tolerance test
• Fasting insulin
• Transferrin
• TFTs
• Beta HCG for females of childbearing age

20
Surgical Options

• Based on 1 of 2 mechanisms for weight loss
• 1. Gastric restriction
• Vertical Banded Gastroplasty
• Sleeve Gastrectomy
• Adjustable gastric banding
• 2. Intestinal malabsorption
• Roux-en-Y
• Duodenal Switch

21
What are the procedures available for weight loss?

• The Malabsorptive Procedures
• The malabsorptive procedures bypass a large
  amount of intestine and weight loss is achieved
  by creating nutritional inefficiency
• DUODENAL SWITCH
• The Restrictive Procedures
• These procedures restrict the size of the stomach
  near the esophagus by creating a restrictive
  pouch. which will hold a volume of approximately
  40cc.
• GASTRIC BYPASS Lap-Band
• Sleeve Gastrectomy

22
The Malabsorptive ProceduresDuodenal Switch

• Fat Malabsorption Primary Mechanism
• Malnutrition an issue
• Fat Souluble Vitamins
• Protein malnutrtion
• Frequent foul smelling stools
• Up to seven per day
• Hepatotoxicity
• Elevated liver enzymes
• Potential for Liver Failure
• Hypoalbuminemia
• Hypoproteinemia
• VERY EFFECTIVE WEIGHT LOSS

23
The Restrictive ProceduresLap-Band

• Pure Restrictive Mechanism
• Requires Frequent Surgical Followvup
• Monthly to Every 6 weeks
• Requires Significant Dietary Changes
• Major Complications
• Band Slippage Reoperation
• Band Erosion Removal
• No Malabsorption Risk
• Reversible
• Low Risk
• Outpatient Surgery

24
The Restrictive ProceduresSleeve Gastrectomy

• Permanent Partial Gastrectomy
• Resection of body of stomach
• Resection of fundus of stomach
• Resection of Antrum of stomach
• Unproven experimental
• Becoming more common
• Not covered by Insurance

25
Combined ProceduresGastric Bypass

• Most commonly performed bariatric procedure in
  U.S.
• Creates a small Gastric pouch
• Creates a short Roux Limb
• Combined Procedure
• Small Malabsorptive limb
• Restrictive gastric pouch
• Difficult to Reverse

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Results of Gastric Bypass

• Average BMI 43.5
• 82 Female 18 male
• Conversions to open 2
• Admissions to ICU post op 4
• 3 sleep apnea observation
• 1 unexpected secondary to conversion to open
• Average Length of Stay 2.2 days
• Outliers 1 gt 10 days

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Results of Gastric Bypass

• Anastomotic leaks -2
• Internal Hernia requiring reoperation 4
• Death lt 3
• Anastomotic Leak Sudden Cardiac Death

28
Outcomes Gastric Bypass

• Effective Weight Loss
• 1 year 68
• 2 year 74
• 3 year 72

29
LAGB Weight LossSystematic Review World
Literature-ASERNIP-S

• Mean Excess Weight Loss

Not statistically significance
Surgery 2004135326-51 J Lap Adv Surg Tech
200313265-70
30
LAGB Weight Loss
A comparison of percentage of excess weight loss
following LAGB and RYGB surgery. Published series
with baseline numbers greater than 501
1 Surgery 2004135326-51
31
Career Experience Gastric Bypass1152 Cases
Major Complications

• Death 3 patients
• Anastomotic Leak 1 patient post op day 3
• Sudden Cardiac Death 2 patients
• No Leak
• No PE
• Internal Hernia Requiring Reoperation
• 6 patients
• Ischemic Bowel Reoperation/Resection
• 2 patients
• Venous Stasis/Thrombosis/Congestion 1
• Arterial Thrombosis/Hypercoagulopathy -1

32
Career Experience Gastric Bypass1152 Cases
Major Complications

• Pulmonary Embolism (No Deaths)
• Post Op Day 1-14 NONE
• Post Op Day 14-30 3
• Rx Prophylactic IVC Filter Pre-Op - (One)
• - Post Op Heparin/Coumadin (Two)

33
Surgical Options

• Roux-en-Y is most common procedure
• Lap-Band Increasing in popularity
• Sleeve Gastrectomy Experimental
• Duodenal Switch
• Laparoscopic pts have less
• Time in hospital,
• Lost work
• Pain
• Incisional hernias (vs 25 in open)

34
Life-Threatening Complications

• 80 of deaths in the first 30 days are due to
• Pulmonary embolism
• Anastomotic leaks
• Respiratory failure

35
Life-Threatening Complications

• Pulmonary Embolism
• Leading cause of death
• Risk factors
• BMI gt 60 kg/m2
• Chronic lower extremity edema
• Obstructive sleep apnea
• h/o pulmonary embolism
• Prophylaxis
• low-molecular-weight heparin and compression
  stockings
• Early Ambulation (laparoscopic)
• Consider Pre-operative IVC Filter

Geerts, W.H., Pineo, g.F., Heit, J.A. et al.
(2004). Prevention of venous thromboembolism the
Seventh ACCP Conference on Antithrombotic and
Thrombolytic Therapy. Chest, 126(3 suppl),
S338-400.
36
Life-Threatening Complications

• Anastomotic leaks Signs and Symptoms
• Sustained tachycardia, severe abdominal pain,
  fever, rigors, hypotension
• Respiratory failure
• Work-up UGI or CT scan with contrast
• May be negative
• DONT DELAY SURGICAL CONSULT
• Urgent surgical consultation
• Exploratory surgery if equivocal signs
• Leak Until Proven Otherwise post op day 1-14
• Identify complications early and educate patients
  about reporting symptoms

37
Life-Threatening Complications

• Internal Hernia
• Partial Small Bowel Obstruction through internal
  mesenteric defects
• Usually following RYGB or Duodenal Switch
  procedures
• Patients complain of severe pain
• Intermittent
• Out of proportion to physical findings
• Usually NOT vomiting
• CT findings usually negative
• Abdominal series usually negative
• Usually occur 12 months or greater post op
• Usually occur after gt100 pounds weight loss
• Surgical Consultation
• Diagnostic laparoscopy and repair of hernia
• Delay in diagnosis can be life threatening

38
Short-Term Complications

• 1-6 weeks post-op
• Wound infections
• Less Common in Laparoscopic Group
• Open Group may lead to incisional hernia
• Stomal stenosis
• Nausea, Vomiting inability to advance diet
• Usually requires EGD and dilation
• Marginal ulceration
• Usually ischemic
• Rarely secondary to Acid production
• PPI (Prevacid Solutab), Carafate suspension
• Constipation
• Poor PO Fluid intake

39
Long-Term Complications

• Nausea, Bloating Abdominal Discomfort
• Think Biliary Dyskinesia or
• Symptomatic Cholelithiasis
• Workup
• Abdominal Ultrasound Gallstones?
• HIDA WITH Biliary Ejection Fraction Dyskinesia?
• Up to 50 due to rapid weight loss
• Consider prophylactic cholecystectomy at the time
  of surgery
• Consider bile salt therapy Daily for 6 months
  post op

40
Long-Term Complications

• Nausea, Bloating Abdominal Discomfort, Malaise,
  Fatigue, Hair loss etc
• Think Nutritional Deficiency
• B vitamins
• Thiamin, Riboflavin, Niacin, Folate, B6, B12,
  biotin and pantothenic acid.
• Fat Soluble Vitamins
• A,D,E,K
• Vitamin C
• Compliance?
• Only 30-35 patients are vitamin compliant

41
Long-Term Complications

• Nutritional Deficiencies
• Especially with malabsorptive procedures (RYGB,
  biliopancreatic diversion)
• Prevention
• Adherence to high protein diet
• Lifelong supplementation
• High potency
• MVI with iron
• Vitamin B12, 1000mcg IM q mo or 100mcg po qd
• Calcium 1200 mg q d
• Menstruating women may require parenteral iron
  infusions

Halverson, J.D., (1992).Metabolic risk of
obesity surgery and lon-term follow-up. American
Journal of Clinical Nutrition, 55, S602-605.
42
Post-Op

• Usually surgeons have their own specific dietary
  transitions anticoagulation methods
• Some recommended ones can be found _at_ UpToDate
• Be aware that in the perioperative period, many
  obesity-related medical co-morbidities change
  dramatically e.g. HTN, DM, GERD

43
Post-Op Monitoring
Virji, A., Murr, M. (2006). Caring for patients
after bariatric surgery. American Family
Physician, 73 (8), 1403-1408.
44
Long-Term ComplicationsCompliance Issues

• Dumping Syndrome
• Procholinergic symptoms from influx of undigested
  carbohydrate into the jejunum
• Side effect of malabsorptive procedures RYBG
  and biliopancreatic diversion
• Symptoms
• Nausea, vomiting, diarrhea, tachycardia,
  salivation, dizziness
• Results from poor dietary compliance may serve
  as reinforcement
• Subsides 1-2 hours after sugar or foods high in
  simple carbohydrate

45
Long-Term ComplicationsCompliance Issues

• Persistent vomiting due to pouch distention
• More common with purely restrictive procedures
  VBG and adj. lap band
• Due to non-adherence to dietary recommendations
• Small portions
• Chewing thoroughly
• Eating slowly
• Waiting one hour after eating before drinking
• Other causes of vomiting pain meds, vitamins,
  dehydration, gastroenteritis

Bohn, M., Way, M., Jemieson, A. (1993). The
effects of practical dietary counseling on food
variety and regurgitation frequency after
gastroplasty for obesity. Obesity Surgery, 3,
23-28.
46
Compliance Issues - Pregnancy

• Pregnancy is contraindicated for at least 18
  months after surgery due to rapid weight loss and
  nutritional requirements
• Provide appropriate contraception

47
Long-Term Complications

• Protein-calorie malnutrition months to years
  after surgery due to anastomotic stricture or
  food phobias
• Repeated episodes of nausea and vomiting
• Multiple hospitalizations for dehydration, renal
  insufficiency and liver failure
• Treat with aggressive TPN, dilation of stricture
• Surgical Consultation for Revision or Reversal

48
Long-Term ComplicationsSide Effects Skin Issues

• Panniculitis
• Severe infection of the excess abdominal skin
• Treat with antibiotics and skin hygiene
• Consider excision of the excess skin

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Results

• Clinical Improvement/Resolution
• Diabetes 64-100
• HTN 62-69
• O.S.Apnea 85
• Dyslipidemia 60-100
• Nonalcoholic fatty
• liver dz 90

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Results

• Cholelithiasis 22
• Overall mortality (after 9 yrs)
• With surgery 9
• Without surgery 28

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F. P. s Role in F/U

• COUNSELLING PT ON LIFE STYLE CHANGES AND
  EXPECTATIONS
• DIETARY CHANGES AMT, LIQUIDS, PROTEIN
• SUPPLEMENTS
• CHANGE IN CHRONIC ILLNESSES

52
Manage Changes In Chronic Illnesses

• DIABETES
• HYPERTENSION
• GERD
• DYSLIPIDEMIAS
• WHEN ?

53
Bibliography

• Virji A, Murr MM. caring for patients After
  Bariatric Surgery. AFP 2006731403-8.
• http//www.hamptonbariatric.com
• USPSTF. Screening for obesity in adults. AFP
  April 15, 2004
• UpToDate
• CARING FOR PATIENTS AFTER BARIATRIC SURGERY. CME
  BULLETIN. AAFP. JUNE 2006.
• MAYO CLINIC PROCEEDINGS. SUPPLEMENT TO OCT. 2006,
  VOL 81.

54
Bibliography

• American Dietetic Assoc Position of ADA. 2002. J
  Am Dietetic Assn. 1021145-55.
• May M. Am I Hungry? What To Do When Diets Dont
  Work. Phoenix Nourish publishing
• Vega GL. Obesity,The Metabolic Syndrome,
  Cardiovascular Disease. Am Heart J, 1421108-16.
• Wadden, TA. (ed). Handbook of Obesity Treatment.
  2002. Ny Guilford Press.

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Thank You!

• ? Questions?